Wednesday, January 12, 2011

How To Get Independent Physicians Into An Accountable Care Organization? Here Some Lessons Courtesy of One Large System

The folks at Advocate Physician Partners (APP) argue that they're a national model for Accountable Care Organization (ACO) wannabes. They're saying that because they assert that they've figured how to out how to "Integrate Independent Physicians." The intrigued Disease Management Care Blog first got a close look at them at the recent Health Affairs "Across The Nation In Health Care Delivery Conference" (second video down) and, when it got snowed in today, decided to take a closer look at their hot-off-the-presses published report.

As the DMCB understands it, Advocate Physician Partners is a 15 year joint venture between a consortium made up of over 2700 independent community-based physicians and the ten-hospital/800 salaried physician Advocate Health System (AHS) located in northern and central Illinois. It appears the independent docs are aggregated into the local physician-hospital organizations that make up AHS. Each PHO sends a delegate to the overall APP Board, which has oversight of an entity that can commit with a “single signature” to HMO and commercial fee-for-service insurance contracts.

All their physicians are required to meet individual clinical and work performance measures. Examples of the latter include their number of active patients in a registry, use of computerized order entry and efficiency measures such as length of stay. APP favors goals that also advantage their hospitals and are common across payers. They cite data collection with reporting feedback, strong governance and enforcement of mandatory protocols as the key to their success. As evidence of their discipline, they noted that the "partnership removed more than fifty physicians for noncompliance with their policies on the availability of information technology."

The published "Integrate Independent Physicians Into ACOs" report linked above is modest about its outcomes (eICU, top ten rankings, HEDIS-based measures, asthma care, generic drugs and electronic data exchange). In contrast, their 2010 Value Report, which seems to be based on extrapolated data, says (on page 7) that they've saved millions of dollars.

What does the DMCB think? While this isn't quite generalizable everywhere, there are some interesting lessons when it comes to wrestling the independent docs into ACOs:

When you’ve seen one ACO, you’ve seen one ACO: The Affordable Care Act may make you think ACOs can be neatly categorized. The mix of players in this physician-led APP suggests that the reality will be a complicated mix of integration approaches. This may complicate CMS' ability to draw any generalizable conclusions about physician-led ACOs that can be effectively used in health reform.

Can’t accomplish this overnight: As noted above, APP had a 15 year head start. The current ACO models don't contemplate taking years to develop a governance structure involving the buy-in of thousands of physicians. Pulling something like this off by January 1, 2012 may prove to be daunting.

The need for speed: While APP is herding cats, they've already demonstrated their ACO chops with a signed ACO-style commercial contract. If you think that's complicated, imagine what the Medicare regulator-lawyers are going to do to this. And they are already - and unsurprisingly - behind schedule.

Only works in a city: While not mentioned above, the Health Affairs manuscript points out that APP has not drawn FTC ire because it occupies only 15% of their local market. Being able to simultaneously fire physicians and maintain a base of thousands of providers is impossible in rural America.

Whither disease management? On page 13 of the 2010 Value Report, there is a mention of "personalized one-on-one professional coaching by health and wellness professionals" but in reading further, the DMCB suspects APP has been largely focused on improving the physicians' day-to-day performance. The DMCB suspects most doctor-dominated ACOs will initially stick to that formula, wasting precious physician time on stuff that non-physician professionals can do more efficiently and cheaply. They all come around, which is the real insight from the note that "personalized coaching" has started. Smart move.

1 comment:

Devon Devine, JD said...

Dear DMCB,

If I am reading this correctly, it is wasteful for physicians to focus on improving their "day to day performance". My take from the APP Value Report, however, is that physicians' deep involvement was a key success factor. It would seem that extensive physician involvement would be a pragmatic necessity in any medical practice's transformation to an ACO.